What is a Smile Makeover?

When someone wants to improve the overall appearance of their smile, this can be accomplished through a series of cosmetic dental procedures which, together, are referred to as a smile makeover. A smile makeover, when done by a qualified and creative dentist well-versed in cosmetic procedures, can completely change a person’s mouth in an aesthetic fashion, creating a more impacting and attractive smile. Among the various procedures which could be performed during a smile makeover are veneers, gum restructuring, invisible braces to realign teeth, and tooth whitening. With the aid of the newest and most innovative techniques, your cosmetic dentist can remake practically every aspect of your smile. A beautiful smile is more than just white teeth: tooth length and proportions, the smile line (an invisible line that follow the curve of the bottom of your top teeth, which should optimally be mirrored by the bottom ones), tooth placement (if some are crooked or overlapping, or even missing), and the characterization and texture of your teeth are to be considered. All of these areas can be addressed with a smile makeover.

Preparation for Your Smile Makeover

Prior to beginning the smile makeover process, you should visit your dentist to make sure your mouth is healthy and can support the cosmetic procedures. If you have gum disease or a misaligned bite, you will need to deal with those conditions before the smile makeover. Your cosmetic dentist will conduct a thorough examination of the teeth, gums and support structure of your mouth, and after determining what your needs and wants are, they will help plan the list of procedures that will be necessary for your smile makeover. Usually your cosmetic dentist will make a wax or plaster cast of your mouth to assist the various technicians and other dentists who will become involved in your smile makeover; endodontists, orthodontists, oral maxillofacial surgeons, and dental lab techs will all likely play a part. Your dentist may use digital imaging to create a preview of what your smile makeover will look like when it is completed, to ensure that you are satisfied with what the results will be.

What are Some of the Procedures Used in a Smile Makeover?

Tooth Whitening. Whiter, brighter teeth can be attained through various procedures. Using chemical or laser whitening agents (such as the Zoom system), your cosmetic dentist can give you white teeth with relatively little in the way of invasive procedures. Tooth whitening is good for those who are happy with the overall state of their mouth but want their teeth to look younger, healthier, and brighter.

Veneers. If you not only want whiter teeth but are unhappy with their shape and positioning, veneers are an excellent choice. There are various types: porcelain, which require a small amount of tooth material to be shaved off to allow for the porcelain to be adhered to the surface; and brand-name “ready to place

What are Dental Implants?

Dental implants are small titanium pegs which are surgically inserted by a qualified dental professional into the jawbone. These pegs will, as the bone heals, graft to the bone, in a process called osseointegration, and will serve as a supportive “root.

GME is working with world-renowned partner hospitals in India to provide the medical care for patients who are in urgent need for the CCSVI / Liberation Treatment.

GME partners exclusively with only JCI-accredited hospitals. Joint Commission International (JCI) - the gold standard for hospital accreditation - is a U.S. based not-for-profit organization - an affiliate of the Joint Commission that accredits over 17,000 health care organizations and programs in the U.S. To receive this accreditation, hospitals must voluntarily commit to a rigorous survey process and demonstrate the highest standard in patient care and enhanced patient safety for a period of time. It is very important that you prefer to get treatment only at a JCI-accredited International Hospital. This is particularly true with increasing importance of Hospital Quality and better treatment outcomes. This ensures that the hospitals are either at par or even better than some of the Best U.S. and Canadian Hospitals. To know more about JCI, please click here.

In India, patients are tested immediately for MS and treatment is on the same day/next day as testing. There is no waiting list for this testing and treatment yet, so contact us immediately to reserve your Liberation.Moreover, the GME management is working to provide this service in other countries as well and will be updated through the website as soon as it becomes available.

Below is a detailed description of the step-by-step approach to be followed by the GME team in your pursuit for Liberation Treatment:

Step – 1 Filling up the required forms.

Getting a preliminary diagnosis done at a local diagnostic center. A variety of tests like MRV, MRI of cervical region, Doppler Ultrasound, etc. are required to be done as per the protocol set by the experts in this field.

If you are facing issues in getting your preliminary diagnostic tests done at your local center, you can choose to get the entire package done in India. Even if you are diagnosed as not being an ideal candidate for surgery, chances are that you might still end up paying much less than at your local diagnostic center. There is a small chance that testing in India will yield results that do not permit liberation treatment. By far majority cases are treatable immediately.

Please note that the results of the preliminary diagnosis at your local center may or may not be conclusive enough for the Experts in India to come to a definitive conclusion about your eligibility for Liberation Treatment. Hence, many of the patients prefer to get the diagnosis as well as treatment done at one shot in India.

Once you are ready to explore the possibility of getting the CCSVI treatment in India, you need to fill-out certain forms which will be sent by our Patient Relations Team. Once we receive your forms as well as the medical records, you will be informed about your suitability of getting the Liberation Treatment in India.

Once we receive the above mentioned forms from you and once your suitability of CCSVI treatment is established, GME will be getting a visa-invitation letter within 24-48 hours from our Partner hospital in India. This letter will help you in getting a visa from the Indian Embassy on a priority basis. GME tries to ensure that based on this letter you should be getting a preferential treatment and a visa be issued within a time-frame of 15 working days from the date of application.

On receipt of the visa-invitation letter from the Hospital, GME will help you in your application for the Indian Visa. Alongside, you need to block your dates for the flight and also the date of your diagnosis in India. Our Travel division, FlyGTE, will be coordinating with you in assisting you for the Visa Process as well as the flight bookings. GME and FlyGTE will ensure that your choices and your budget are taken into consideration throughout the process. If you are not in a position to travel immediately on receipt of visa, you can still choose to book your liberation procedure in India for a suitable date in future.

Step – 4 Hotel Booking (Optional).You can also choose to get your hotel booked for your stay in India for the post-treatment recovery period. FlyGTE team will assist you with a variety of hotel packages. However, you also have the option of getting it done after reaching India.

Step – 5 Actual Diagnosis & Treatment in India.

Departure from your nearby International Airport for the journey to India:Depending on your budget and your condition, you can choose to get a flight with only one short layover OR you can choose to stay overnight at one of the layover stops and resume the journey on the next day. However, the decision will be yours as it affects the overall cost of the trip and treatment.

Time frame before departing: After the issuance of your Visa (which takes about 10-15 working days from the date of application), you can immediately travel for your treatment. Currently, there is NO WAIT LIST for accessing the diagnosis and treatment in India.

Arrival at the International Airport in India:Our Care Manager will be at the airport with a placard containing your name. You will then be escorted to the hospital and will be resting for the day. Diagnostic testing consisting of a variety of tests is performed to find out the eligibility of the patient for the Liberation Procedure.

If the patient is found to be not suitable for the Liberation Treatment, then he/she will be discharged in 2-3 days and only diagnostic tests will be charged at the hospital. Rest of the deposit for the treatment will be returned to the patient. However, there is a small chance that testing in India will yield results that do not permit liberation treatment. By far majority cases are treatable immediately. If you get Stenosis confirmed before you leave your country, it reduces the possibility that none will be found in India.

If the patient is found to be a good candidate for the Liberation Procedure, then the actual treatment process will be undertaken. The treatment takes the forms of balloon angioplasties, stent procedures or surgical augmentation of the jugular vein depending on the findings of the testing.

Treatment Duration and Length of stay: Depending on the treatment plan, the length of stay in the hospital can be between 4 and 7 days. Patients are also required to stay in the country post-discharge from the hospital for follow-up visit. Generally, the post-discharge stay is about 4 to 7 days if it is a standard case of CCSVI Treatment.

Post-treatment Support and Continuity of Care:The patient can choose to stay in a nearby hotel depending on their budget. GME is all about choices!! We strive to offer you the best service in line with your medical condition and your financial situation. We do not believe in forcing any standard packages or hotel options without giving due attention to your individual needs. GME and FlyGTE team will help the patients in booking an appropriate hotel well in advance. Some patients also choose to go for a recuperation and alternative healing package in a Wellness Resort or Spa. Patients will be given adequate choices well-in-advance to come to the best decision depending on their condition.

GME’s Affiliated Doctors Network:GME has a large network of affiliated Doctors to ensure continuity of care for the patients once they return home. Patients can have constant follow-up, regular testing and address any concerns that they might have post-treatment through our network of doctors.

GME's Dedicated Care Manager will be there to assist the patients all throughout their stay in India. Additional facilities like cell phone, internet access, etc. will be made available to the patient as per their request. Moreover, the friends and family members of the patients will be given regular timely updates about the treatment progress of the patient.

Please talk to our Doctor to get personalized guidance about the process of CCSVI Treatment through GME.

GME has its main office in California and also in India. This ensures that there is 100% coordination closer to you

GME has a large network of affiliated doctors. This ensures regular follow-up and continuity of care once you return home

GME partners exclusively with JCI-Certified hospitals. This ensures you get the same or better quality of treatment than what you get in North America

The doctors in India at GME’s partner hospitals have got extensive training for CCSVI

GME has experienced Doctor Team with International Experience on its staff

There is no waiting time for accessing CCSVI Treatment through GME

GME provides dedicated Care Managers who will be there to assist you throughout your stay in India

GME maintains an Ethics & Quality Board comprising of some of the best doctors in the field in every country that it operates in

GME ensures that you get the Highest Quality Care at the most affordable rates

Global Medical Excellence (GME) is headquartered in Anaheim (California) and specializes in providing a variety of Local and International Treatment options to North American patients across various specialties.

Here are the unique differentiating points about GME

GME partners exclusively with only JCI-accredited hospitals. Joint Commission International (JCI) - the gold standard for hospital accreditation - is a U.S. based not-for-profit organization - an affiliate of the Joint Commission that accredits over 17,000 health care organizations and programs in the U.S. To receive this accreditation, hospitals must voluntarily commit to a rigorous survey process and demonstrate the highest standard in patient care and enhanced patient safety for a period of time. It is very important that you prefer to get treatment only at a JCI-accredited International Hospital. This is particularly true with increasing importance of Hospital Quality and better treatment outcomes. This ensures that the hospitals are either at par or even better than some of the Best U.S. and Canadian Hospitals. To know more about JCI, please click here.

GME has a unique Global Provider Network consisting of some of the best doctors in various specialties. This network of GME-affiliated doctors ensures pre and post-operative care for patients of major specialties and maintains a continuity of care in its truest sense. At no point after your return home, you will feel left out or unassisted. This is one of the biggest differentiating points that set GME apart from other organizations. To check our doctors profiles please click here.

GME has some of the best doctors on its staff having extensive experience in the field of International Healthcare. You can feel free to talk to any of our doctors by calling our Toll Free Helpline – 866.463.2111. This is unlike any other company offering similar services. While making an important decision of availing treatment abroad, you cannot afford to leave your health issues in the hands of professionals with no experience on the clinical aspect.

GME has offices in multiple countries with the provision of dedicated Care Managers for each and every International Patient that makes use of its services. GME is there for you wherever you go.

GME maintains a unique Ethics and Quality Board comprising of some of the best doctors in the field in every country that it operates in.

GME is all about choices. We offer the maximum possible flexibility to the patients in making their healthcare choices giving due consideration to their medical, physical and financial condition.

Please talk to our Doctor to get personalized guidance about the process of CCSVI Treatment through GME.

Bags under the Eyes (Lower Blepharoplasty)

Overview

Getting older is a fact of life that few of us like to admit to. Consequently, visual signs of aging are particularly unwanted and can be the cause of considerable loss of self-esteem. As some people age they are particularly prone to a build-up of excessive pouches of fat and loose skin beneath the eyes, often detracting from their once-youthful and attractive eyes and making the individual look tired and dispirited, whether that is so or not.

The skin under the eyes is quite delicate. This is the reason why it is prone to sagging, discoloration and wrinkling. If you do not take good care of the skin surrounding this area, you will look older and more mature than you really are. So, when you look in the mirror and your reflection looks as if you are in a chronic state of stress and the weight of the whole world is on your shoulders, a lower blepharoplasty, or lower eyelid surgery, might be the procedure to help you get rid of problems concerning the skin around your eyes, particularly eye bags.

What Causes Eye Bags?

Eye bags tend to run in families so, if your parents appeared to suffer from this problem as they aged there is every possibility that you will too. Other causes of eye bags tend to be:

Habitual fatigue and stress

Being deprived of sleep

Smoking

Allergies

Thyroid not functioning properly

Another cause of eye bags developing also include too much exercise or over-exerting yourself according to clinical studies. A poor diet has also been attributed to bags developing beneath your eyes, especially individuals whose diets consist of too much salty food and insufficient water. Furthermore, people whose diet consists of processed food that is also high in sugar are also considered susceptible to the development of bags beneath their eyes. This has been attributed to additional free radicals circulating through the body, causing levels of oxidative stress that is too high. This is the cause of sagging skin and puffiness around the eyes, resulting in premature aging according to the May 2008 edition of the European Journal of Clinical Investigation.

What Exactly are Bags under the Eyes?

People susceptible to puffiness underneath the eyes often begin to show signs during their 30s. Apart from the skin losing its elasticity and sagging in response to the effects of gravity on loose skin, the fat layer in the peri-orbital area of the eyes, on which your eyeball balances, sags along with the loose skin and over-stretched muscle causing the unsightly eye-bags. Statistics reveal that men aren’t immune to wanting to look younger and, nowadays, more and more are booking cosmetic procedures. The latest figures reveal that surgery to remove bags from underneath the eyes accounts for up to 21% of all cosmetic procedures that are requested by men, with up to 60% of these being for the over 50 age group.

Surgery to Remove Eye-bags

Surgery to remove these bags under the eyes is not an inexpensive option but it can be very effective and create an incredible boost to an individual’s self-esteem. Surgery that is carried out to remove this excess fat, including the loose skin and sagging muscle beneath the eyes, in the periorbital area, is known as Blepharoplasty. Altogether, including the immediate pre-surgical tests and consultations, the surgery to remove bags under the eyes will take around 14 days.

Are You Suitable for Blepharoplasty?

If you are considering cosmetic surgery of any kind you need to ensure that you consult a reputable surgeon. Furthermore, any reputable clinic will make sure you have a full pre-surgical consultation during which detailed information about your health will be taken, you will be given a thorough physical check-up and the surgeon you are consulting will establish whether you are suitable for this kind of surgery. In other words, the surgeon will establish why you have decided to have this kind of surgery and what you are most concerned about. Your surgeon will also take a detailed medical history, including information about your family.

Before agreeing to operate on your eyes the surgeon will want to establish exactly what your expectations are with respect to surgery to remove bags from under your eyes. This is important because you are not going to stop the aging process. Instead, you will appear more rested and refreshed which can contribute to a more youthful attitude and appearance. No matter what kind of surgery you have, no surgeon is going to be able to provide you with the face of the dewy-eyed 18 year old you once were. You will also be advised that, no matter how well the surgery goes, the kind of result achieved will depend on the kind of skin you have – and that, in part, is determined by your genes.

Finally, your surgeon will make you aware that it could take up to a year before the full effects of your operation to remove the bags from under your eyes is achieved. After you have had your stitches removed, you will notice some improvement and, after that, month by month, the improvement continues. However, you will need to be patient and realize it could be a full 12 months before the best effects will be clear.

How is the Surgery Carried Out?

Laser surgery has revolutionized many cosmetic surgery techniques and surgery to remove bags under the eyes is no exception. The surgeon usually makes an incision along the natural folds of the eyelids, although some surgeons will operate by making an internal incision. This latter procedure leaves no scars visible from the outside which, of course, is a preference in any elective cosmetic surgery. However, Blepharoplasty is not always carried out for cosmetic reasons. It is sometimes performed to improve an individual’s peripheral vision.

After being admitted to the outpatient clinic or day surgery unit the surgeon will arrive to have a chat and get you ready for surgery. You may be surprised to see him arrive with a marker pen or ‘Sharpie’ which he will use to draw on your skin so that he operates in the correct place. Once you have signed the consent form the surgeon will answer any questions you might have and will do everything possible to put your mind at rest. After this last consultation you will be ready for surgery to go ahead. Once you get down to the operating room the total time you can expect for your operation is between one and three hours. Lower blepharoplasty can carried out under local or general anesthetic, usually in a day surgery unit or outpatient clinic with surgical facilities.

Once the incision has been made your surgeon will separate the subcutaneous layers of skin from the top layer of skin and trim away any excess fat, as well as repairing any loose muscle or skin that is sagging. Once the surgeon has finished the actual surgery the incision will be carefully closed using very fine sutures or surgical glue. For Blepharoplasty on the lower eyelids the surgeon will extend the incision 1cm out to the edge of your eyes, into the crows’ feet area and then lift the skin up and outwards. The skin is carefully teased away to separate out the layers, enabling the surgeon to once again remove any excess tissue from the area before finally closing the incision in a way that prevents any scarring from showing.

Immediately Post-Surgery

The first thing you will probably notice is swelling and bruising around the eye area. These can take ten to fourteen days to heal properly, although you will find that the healing process can actually take a few months. Along the line of your eyelashes you will notice some pink scars which, once healed, fade out very quickly. Immediately after surgery you will have icepacks over your eyes to help reduce swelling and bruising as much as possible. You will also be given adequate pain relief to help you cope during the immediate post-op period, as well as eye ointment that you will need to keep applying. The swelling and bruising is at its most severe in the first two or three post-operative days, usually subsiding slowly after that. Make sure you protect your eyes from UV light during the healing process: a pair of dark glasses will protect your eyes as well as hide the bruising from immediate view. You will also be advised not to rub your eyes or rub your eyelids with a towel.

Once you have had your surgery, before being discharged home, you will be advised about follow-up treatment and be allocated a nurse counselor to provide you with any support you may need or to provide you with answers to any questions that you may have. A post-operative appointment will be made for you to see your surgeon. It is essential that you attend this appointment to ensure that everything is healing properly and there is no post-operative infection developing at the incision site.

What to Expect Following Surgery

Once the bruising and swelling have subsided and you have had your stitches removed you will notice that you no longer look drawn and tired all the time. No amount of surgery is going to remove the mark of years from your skin, but men especially who have undergone surgery to remove bags from under the eyes notice that they look around 10 years younger than prior to the operation. You will look more refreshed and, probably due to an increase in self-esteem and self-confidence, you will appear more positive and energized, with a more ‘opened’ look to your eyes.

Risks Associated with Surgery

Since this operation can be carried out under local anesthetic the risks usually associated with the administration of anesthesia are considerably reduced. Generally, the risks associated with this kind of surgery to remove bags under the eyes tend to be:

Vision that might be blurred or impaired slightly. This only temporary, however.

Dry Eyes

Difficult to close eyes

Your lower eyelid may pull down. Again, this is only temporary.

Alterations to skin sensation or numbness in the area around the eyes

Eyelid ptosis. This is an abnormal positioning of the eyelids

Persistent pain

Ectropion. This involves the area around your lower eyelid being more lax than normal, causing your eyelids to roll outwards. This can also be associated with sagging brow and forehead.

Poor wound healing, infection, bleeding, blood clots – all of which are associated with normal surgical complications. Also included could be the risk of DVT, and complications involving your heart or lungs.

Fluid accumulation

Spontaneous surfacing of sutures, poking through the skin and causing discomfort and irritation

Loss of eyesight

Possibility of revisional surgery

Additional Information

The cost of surgery to remove bags from beneath your eyes will not be covered by health insurance since it is considered to be a cosmetic procedure. The costs vary from clinic to clinic and from country to country. However, in the USA the costs average from $2,000 to as much as $6,000 depending on the intricacy of the operation. In the UK the cost is approximately $3,900 USD. These costs include the pre-surgical consultation, the anesthetists, the cost of the surgeon and the cost of the operating room facilities.

Cosmetic surgery is not an inexpensive option and prevention is obviously better, and cheaper, than a surgical cure. Obviously, you can do nothing about the genes you have inherited. However, you can pay attention to your lifestyle, including your diet and whether or not you smoke, how much you exercise, and how much alcohol you consume. Ensure you eat plenty of fruit and vegetables as they contain polyphenols that help to mop up free radicals caused by the oxidation process that occurs during cell metabolism. You also need to ensure you get sufficient sleep. Paying attention to these details will help reduce the impact of aging on your skin and, possibly, prevent bags under the eyes from developing to the extent that surgery is needed.

Upper and Lower Eyelid Surgery (Blepharoplasty)

Overview

As we age the delicate skin around the eyes tends to sag as the underlying structures in our skin weakens and often sags along with the skin. The appearance is a tired, haggard-looking face that often results in low self-esteem and a poor self-image. This is hardly surprising when you consider that the eyes are one of the first things people notice about you. In fact, people you encounter form their first impressions of you within seconds of meeting you and, rightly or wrongly, aging eyes tell them a story that perhaps may give them an incorrect impression of who you are, what knowledge you have and what is important to you. Most often wrinkling and sagging can be the result of the normal aging process.

However, they can also reflect an erratic lifestyle, as well as smoking, drinking, too much stress, too little sleep as well as skin allergies causing eyes to puff up. Quite often premature aging can be alleviated by upper and lower eyelid surgery. While all surgery carries a certain amount of risk, surgery to correct aging eyes is a remarkably safe procedure that carries a particularly high level of satisfaction to the patients who undergo surgery. It is important to mention that not all surgery for upper and lower eyelids is done for cosmetic reasons. Sometimes sagging eyelids occur as the result of skin allergies or from kidney illnesses, as well as blepharitis which is an inflammation along the rims of the eyes. Surgery is sometimes needed to correct problems caused by these conditions.

Anatomy and Physiology of the Eye

As you will be aware, you have an upper and lower eyelid to each eye, each one lined with eyelashes. As our bodies are in 3D, as it were, your eyelids have an edge along which upper and lower eyelids meet. The edge of the eyelids is known as the eyelid margin, with an internal margin and an external one. Your eyelashes are attached to the outside edge of the margin. When your eyelids are open your eyeballs are exposed so that you can see what is around you. The open gap between upper eyelid and lower eyelid is referred to as the palpebral fissure. When you close your eyes together your eyelids meet together.

The line along which they meet is known as the commissures, with the medial commissure being nearest to the nose and the lateral commissure being the one furthest away from your nose. At the medial commissure eyelid margin your eyes drain into the tear ducts known as the lacrimal puncta. Below the skin, lying on top of the bone of your skull is the soft tissue, collectively known as canthi. Each canthus would be muscle, epidermis which is the lower level of skin, tendons, and fat. The medial canthus and the lateral canthus each extend for half an inch either side of your eye. A large muscle that completely encircles each of your eyes is the orbicularis muscle which allows your eyelids to close, with the levator muscle opening your eyes.

The levator muscle originates deep inside your eye socket and extends towards the top of your eye, where it meets the flap of your eyelid. Here it has evolved into the levator aponeurosis tendon that physically attaches the muscle to your upper eyelid. Meanwhile, the frontalis muscle lies across your forehead, enabling you to pull up each of your eyebrows and wrinkle your forehead. Horizontal wrinkles are the result of skin between each eyebrow being pulled by the procerus muscles. If you decide to wrinkle your nose up and push up the skin between each of your eyebrows you will be utilising your corrugator muscles. The only muscle involved with the movement of your actual eyeball itself is the inferior oblique muscle that may be disturbed when the fat from your lower eyelid is removed, although there are actually six muscles that your eye relies upon to control movement.

Your eyelids are supported by a layer of thin cartilage strung from lateral to medial corners of each eye. This is the tarsal plate that is attached to either side of your eye by tendons that attach it to the bone of your skull, at your orbital rim. The medial side by the nose is called the medial canthal tendon whilst the lateral canthal tendon is found at the outside edge of your eyelid. In other words, to put it more simply, you have the tarsal plate along the inside of your eyelid, attached at each side by a tendon, in a hammock-like construction known as the tarsoligamentous sling. A similar system operates the top eyelid, similar to that of the lower eyelid.

Medial Canthal Tendon anchoring lids to bone

Lateral Canthal Tendon anchoring lids to bone

Upper Tarsus or Tarsal Plate. This is stiffens like cartilage

Lower Tarsus.

Levator muscle as far as tendon. Main opening muscle of upper lid

Superior Oblique tendon – this moves the eyeball

Inferor Oblique muscle – also moves eyeball

Lacrimal Gland – otherwise known as the tear gland

Lacrimal Sac – part of tear drainage system

Fat Orbital – extends into eyelids

Orbital rim – bony socket

Your eyeball is cushioned from contact with the inside bony surface of the orbital socket with a padding of fat covered by a thick fibrous membrane called the orbital septum. This connects with the tarsoligamentous of the lower eyelid and attaches up to the bony rim of the orbital socket. Meanwhile, the orbital septum for the upper eyelid extends as far as the bony rim above the eye. These orbital septa cover the pad of fat the covers the levator aponeurosis tendon. In the upper eye there are two fat pads whilst there are three fat pads in the lower orbital area, referred to as the temporal, middle and nasal pockets.

Meanwhile, your eyelid crease is formed from extensions of the levator aponeurosis tendon. The capsulopalpebral fascia is a set of small muscles and tendons that make small movements to your lower eyelids possible whilst the deepest muscle of all within your eyelid is the Muller’s muscle. This is not touched during upper and lower eyelid surgery. Other important structures that tend to be involved in surgery on your upper and lower eyelid include the suborbicularis oculi which is a layer of fat at the lower end of your orbicularis muscle as well as another fat pad known as the malar fat pad which extends from below the base of the orbital bone towards your cheeks.

Why Do Your Eye Lids Begin to Sag?

Basically, a lot of this is determined by your genes and, if your parents suffer from sagging skin around your eyelids, you will be more likely to as well. However, the physiological effects of drooping eyelids, baggy pouches and a general sagging is due to the effect of aging on the face, exacerbated by the effects of gravity. As you age your eyelids begin to stretch as elasticity in the skin is lost, causing an overhang in the upper eyelids. Your skin is particularly thin around the area of your eyes so, as collagen begins to lose some of its natural fluids, wrinkles develop. As skin continues to thin more of the orbital fat is revealed, often making it look as if it has herniated through the protective support fascia even when it hasn’t.

As time progresses fat continues to be absorbed from the face, resulting in skin that increasingly sags. In fact, loss of fat from the face tends to be considered as one of the primary causes of sagging skin around the eyes. As fat becomes absorbed and skin starts to stretch due to the aging collagen, the orbicularis muscle also gets stretched. This makes it thinner and more prone to stretching itself due to less strength in the muscle fibres. The whole result is the slow collapse of the support system around each of your eyes.

As if this wasn’t enough, your brow begins to lower due to the loss of elasticity in the frontalis muscle. This is the ultimate cause of the skin of your eyelid rolling over. There is a section in your face just slightly lower than you bottom eyelid. This is referred to as the tear trough. As the aging process continues all the soft tissue begins to gravitate through this small area as gravity exerts a force more powerful than the lost elasticity of muscle fibres, eventually allowing the bony orbital rim to be revealed around the eyes, a process known as skeletization. Another quite noticeable condition might be a mound of fluid around the lateral corners of your bottom eyelids. This is known as the malar mound. If often appears as a purple color and is often associated with a diet too high in salt.

Pre-Surgical Consultation

The idea of upper and lower eyelid surgery is to remove the fatty pads that have prolapsed through the orbital septum, as well as to remove the loose and saggy skin that gives a droopy impression prior to surgery. Pre-surgery consultation needs to take place with the surgeon or a member of the operating team. This includes a complete medical examination. The kind of questions your doctor will ask you will be whether you suffer, or have suffered from any chronic illnesses such as kidney disease, diabetes, congestive heart failure or thyroid disease as any one of these could have a potential effect on the tissues around your eyes.

If everything is in order and you are declared fit for surgery you will usually be given an operation date within 2-4 weeks. You will be advised to make sure you get plenty of sleep so you feel fresh and fit for your operation.

What the Surgery Involves

If you are intending to travel abroad to have this surgery carried out you need to ensure you are prepared to allocate at least 10-14 days for the surgery to be completed successfully. This includes the initial consultation, any imaging or tests necessary, the operation and immediate post-operative period and the start of your period of recuperation, including having your stitches removed. The surgeon is careful to ensure that the scar is well concealed amongst natural eyelid folds. Any loose skin and prolapsed fat will have been removed and you will begin to look and feel better as soon as the bruising and initial swelling subsides.

The operation for both upper and lower eyelid surgery can usually take up to three hours. During upper eyelid surgery the incision is made along the line of the natural eye crease while the incision for the lower eyelid is just below the eyelashes. If you are just having excess fat removed beneath your lower eyelids, without skin removal, the surgeon will often carry out a transconjunctival blepharoplasty, where an incision is made, the fat is removed and the incision is closed with tiny sutures. Overall, this is a minor operation that is habitually done under local anesthetic, although an intravenous line is usually inserted to provide you with sufficient sedation so that you are completely relaxed during surgery.

Once surgery is formally finished you will have your eyes lubricated with an ointment containing an antibiotic to prevent infection. Once your anesthetic wears off you might find your eyes feel sticky from the eye ointment will be sore and rather blurry, although the actual suture line will remain numb. Your eyes will be sensitive to light and, for around 10 days following your operation, your eye area may be swollen and bruised.

What to Expect During Recovery

You should hardly notice the incision after about two to three months, although it may remain pink for quite a few months. Any stitches are usually removed by about the 5th day and, by the 10th day you are usually ready to resume your normal lifestyle. Your eyes will be very sensitive for some weeks so make sure you protect your eyes with some good UV sunglasses. If you wear contact lenses, you will need to leave them out for a few weeks until your recovery has progressed enough that it is safe and comfortable enough for you to re-insert them.

Risks Associated with Surgery

There are very few risks associated with upper and lower eyelid surgery, apart from the risk of infection. However, patients sometimes report dry eyes and double vision during recovery and, very rarely, delay in wound healing.

Spinal Fixation

What is the Reason for Spinal Fixation?

Where your spine, for whatever reason, has too much movement or is not sufficiently stable by itself to support the necessary stresses and strains that tend to be put on it on a daily basis, then spinal fixation is often the answer. People who suffer considerable pain on movement, or when they experience tingling in an arm or a leg might be considered for spinal fixation if the cause is due to movement in the spine putting pressure on one of the nerves. Furthermore, if a person experiences numbness or weakness in an arm or leg this could be due to spinal compression, with the bones in the spine pressing on an adjacent nerve. Spinal fixation will fuse the bone in the area that is causing the problem, making a more rigid support that is also more stable.

How Did Spinal Fixation Develop?

Setting broken bones, in the past, involved the use of plaster casts made from plaster of Paris, to hold the bones in one place to enable healing. If bones move around too much when they need to heal, the cells involved in the process of healing will not be able to complete their job properly and the broken bones will heal badly, if at all. More recently, internal fixation has become the norm, using screws and plates to hold damaged bones together. The rigidity of the metal plates provides the necessary support that prevents movement as the bones knit together. There are many fractures that actually respond better to internal fixation, as well as being more comfortable for the patient.

Spinal support was largely reliant on external fixation and, in some cases, still is. However, internal metal plates, rods and screws are increasingly taking the place of what many people view as barbaric-looking external fixation devices. Support within the body has a number of advantages which are discussed in more detail later. Largely, however, a more rigid structure is achieved with internal fixation allowing for enhanced healing. Greater support is achieved enabling the patient to mobilize much more quickly after surgery, thereby reducing the chance of DVT and embolisms developing through sluggish blood flow. Patients are often able to return to their normal daily activities within 6 weeks of surgery, including a return to work in most cases, which has a far greater psychological and sociological outcome for all concerned.

Anatomy and Physiology of the Spine

The musculoskeletal system of the spinal area is quite complex so it is hardly surprising there are so many things that can go wrong with it. Two of the most common kinds of pain you can experience are from pain in the neck and pain in the lower back but, because of the sheer complexity of the anatomy and physiology of the spine any pain you experience in any areas of your spine could be caused by a range of conditions making these kinds of problems quite difficult for clinicians to diagnose, especially if the pain emanates from one of the facet joints. This condition causes chronic pain and, on the occasion it is diagnosed correctly, is known as Facet Syndrome, or Facet Joint pain.

Distinct Divisions of the Spine

The spine is made up of a series of very distinct areas, each containing a number of individual bones. Each section has a slightly different function although, overall, the spine is intended to provide support for your muscles and tendons and to provide protection for the spinal cord. The bones that make up the spine are each called vertebra, with 33 vertebrae making up the whole length of the vertebral column. The spine is divided up into:

Cervical vertebrae – 7 bones

Thoracic vertebrae – 12 bones

Lumbar vertebrae – 5 bones

Sacrum: these are fused vertebrae, consisting of 5 bones

Coccyx: this is the vestigial tailbones, consisting of 4 very small bones

Cervical Vertebrae

These tend to be labeled C1 – C7 and are responsible for the movement of the neck as well as providing protection for the top of the spinal cord together with other nerves and arteries that, in this area, are quite major as they extend into the skull and connect the brain with the rest of the body.

Thoracic Vertebrae

The 12 vertebrae making up the thoracic vertebrae are referred to as T1 – T12. These are the vertebrae that form the back of the rib cage.

Lumbar Vertebrae

The lumbar vertebrae are often referred to as the ‘small of the back’. They consist of 5 bones, referred to as L1 – L5. This is a very common area to experience back pain as the lumbar region takes considerable stress from the amount of weight placed on it.

Sacral Vertebrae and Coccyx

Together these consist of 9 bones, all of which are fused together in adulthood. The sacrum is generally referred to as S1 and consists of a single unit of bone.

Inter-vertebral Discs

These discs intersperse the above bones of the vertebral column.

Each one is a flexible cushion of tough, cartilaginous material that prevents friction between the bones and provides protection against potentially damaging jarring when moving. The shock absorbing qualities of each disc is achieved through the nucleus pulposus, a spongy liquid that absorbs any shocks, each of which is surrounded by a tough fibrous membrane. In cases where discs herniated through this outer membrane this interior jelly can press against nerves in the spinal cord, causing severe pain. The vertebral bones are put together and tend to be the cause of many of our spinal problems, as well as fulfilling a very essential function within the body. Aside from protecting the spinal cord, the spine serves as a conduit through which all the major information from the brain reaches the network of muscles, nerves, bones, tendons and ligaments through which neural information is disseminated to every cell within the human body. In situations where illness or injury causes the spine’s function to be impaired, without active intervention the results could lead to chronic and debilitating pain as well as causing major disability.

Spinal Cord

The spinal cord runs through the vertebrae, from the base of the brain to the lower end of L1, lumbar vertebra. The cord itself is protected, not just by the overarching bones of the vertebral bones, but by a particularly tough membrane known as dura mater. This completely encloses the spinal cord within a waterproof casing, within which is spinal fluid that helps to provide additional protection as a shock absorber for the spinal cord encased within. Each part of the body is joined to specific nerve roots that leave the spinal cord at certain points. The nerve roots in the cervical area of the spine provide neural support for a network of nerves over and around the arms and upper chest while the nerve root leaving the lumbar area supply nerve stimulus to the buttocks, hips and legs. If these nerves are damaged, or compressed, you will experience symptoms such as tingling, numbness, weakness or pain of varying degrees. This can be felt not just in the immediate vicinity of the injury, but as referred pain elsewhere in your body.

Muscles of the Spine

There are actually 7 layers of muscles that are responsible for moving the body and limbs around, each one of them surrounding the vertebral bones. As you can see from the diagram, they are responsible for maintaining an upright posture and being able to carry loads and undertake normal day to day activities. Damage to the spine can interfere with the activity of these muscles, causing weakening or even preventing movement from occurring with any ease.

Normal Spinal Curvature

If you look at a normal spine you will note that, when viewed from the front or the back, the spine appears to be a straight line. Should the spine appear to curve to either side when looked at from this view, it is indicative of scoliosis. In a normal spine, when looked at from the side, there are three gentle curves, two inward and one outwards. The cervical spine and the lumbar spine both exhibit an inward curve. This is medically referred to as a lordotic curve. Meanwhile, the thoracic spine curves outwards. This is known as a kyphotic curve. The way the spine curves is adequate to support the weight of the upper body and the head as well as to maintain a suitably upright balance. If curvature is too extreme the spine could become too imbalanced, causing pain and disability.

Vertebrae. These consist of pedicle supports which are bony parts that provide an arch of bone across the spinal cord. The back of this bony arch consists of the laminae.

Intervertebral Disc.

Facet Joint. This joint connects the bony arches together. Each pair of vertebra has two associated facet joints, one above and one below. The facet joint is a synovial joint that enables each vertebra to pivot around, enabling rotating movement to occur.

Neural Foramen. This is an opening beneath each vertebral arch that enables the nerve roots to leave the spine to join up with other parts of the body. Each pair of vertebrae are associated with two neural foramen. The function of the neural foramen is to protect the junction of the nerves where they join the central nervous system.

The spinal cord runs the length of the vertebral column and is protected along its length by the interlinking vertebrae, the pedicle arch and their associated facet joints. The spinal cord runs from the base of the brain to the end of the 1st lumbar vertebra, where L1 meets L2 after which it frays out into a number of lesser nerves, each one major in their own right. The medical term for this is cauda equina as its appearance is that of a horse’s tail.

When Things Go Wrong

This very complex system of our musculoskeletal framework, with its interspersed network of nerves can be the cause of things going wrong, often something quite small can send quite major signals of pain to the recipient. The nerve roots that leave the spinal cord are extremely sensitive, not just to alterations in posture or movement but to pain. Facet joints in the lumbar vertebrae are also particularly sensitive to pain so it is hardly surprising that so many people experience prolonged periods of incapacitation due to chronic pain in the lumbar region of the back.

When pain is experienced from subluxated facet joints or from impinged spinal nerves the muscles of the trunk are quick to respond. Muscles contract when the nerves supplying them are damaged in any way, resulting in muscular spasm which can be extremely painful. If any of the five sciatic nerves in the small of your back are impinged in any way you can experience a particularly painful condition known as sciatica. This often occurs if there is something pressing against any of these nerves. Apart from the pain, it can cause tingling and numbness in the gluteal muscle of the buttovcks and down both legs into feet and toes. If this continues, muscles can become weak and will eventually atrophy.

Imaging Tests

Accurate internal fixation has largely been achieved through the development of more accurate imaging techniques such as MRI scanning and bone scans using special dyes that show any boney defects in far greater detail than any X-ray could ever achieve by itself. There is still a place for X-rays, especially the various techniques associated with X-ray technology: X-ray is a far cheaper imaging technique than MRI or CT scans, for example. Diagnostic injections that insert a special dye into the body certainly produce far better results than what was available before these were sufficiently well developed to be of any use. Skilled clinicians trained in these new techniques have now come of age as well, with surgical training keeping pace with these new diagnostic tools. This ensures that surgeons are able to implement these technological advances while, at the same time, have the necessary skills to operate and use them to fix the spine more effectively.

Advances in Fixation Materials

Better rods and screws have certainly made a great difference to spinal fixation methods. A provisional patent was applied for in July 2008 for screws made from bio-absorbable material. This material combines the strength required for internal fixation with the advantages of not having metal encased within the body, especially relevant in terms of MRI testing, for one thing. One particular bio-absorbable screw for bone fixation has been awarded US patent number 5.470.334; others can be found under US patent number 4.968.317. Whether these bio-absorbable materials will completely replace the Kirschner apparatus that includes the various stainless steel pins and interconnecting rods used for internal fixation and the clamps, together with nuts, used for external fixation, remains to be seen.

When is a Spinal Fixation Necessary?

Surgery to correct spondylolisthesis, which results in spinal bones becoming unstable and pressing on major nerve groups, is one condition which often makes spinal fixation necessary. This condition often results in patients developing bone spurs and protrusions of spinal discs. These are usually moved away from the spinal cord and any nerve roots at the time of surgery. In order to do this, it is often necessary to remove these: this causes further de-stabilization of the bones in the spine, necessitating the use of rods and screws to prevent the bones from slipping any further.

Scoliosis: Scoliosis, which is when the spine bends into abnormal positions, is another condition that can be successfully corrected with the use of rods and screws. When scoliosis results in the spine curving too much for the patient to be comfortable, it often becomes necessary to insert rods to correct the spine’s continued curving.

Infections: Infections and tumors also often result in bones becoming unstable, making spinal fixation necessary while the patient has the underlying cause treated. Removing tumors from the spinal region can reduce pain caused by the developing tumor, while spinal fixation can help the patient remain mobile, reducing the possibility of DVT and other blood clots from developing as well as improving the patient’s psychological outlook, enabling them to better cope with their illness.

Fractures: Fractures need to be dealt with on an individual basis depending where they occur in the spine. Statistics report that as much as 90% of all spinal injuries occur in the thoracolumbar region of the spine. Out of these between 10% - 20% are burst fractures. These are fractures that occur as the result of vertical compression when the spine is slightly flexed. Burst fractures can also occur as the result of a rotational injury. These burst fractures have been described in terms of different mechanisms of injury that can become intensely complex and detailed. Suffice to say that any injury to the spine that results in bone fragments being propelled towards the spinal canal, or where the vertebral pedicles are fractured, are considered to be major burst fractures and the source of severe injury that needs some form of spinal fixation to prevent further damage.

Burst fractures in the thoracolumbar region can result in neurological damage whereas an effective repair can result in an opportunity to heal with few problems. Spinal instability was adequately defined by Nicoll in 1949. This definition was based on the degree of subluxation or dislocation and the degree of disruption to interspinal ligaments, including if relevant, laminar fractures of lumbar vertebrae, L4 or L5. This definition is so respected in surgical circles that, even after more than 50 years, Nicoll’s definition continues to be used in decisions of how to treat these fractures. A decision to undertake spinal fixation needs to take into account the degree of mechanical and neurological instability caused by the injury and considers how appropriate the spinal fixation would be in terms of recovery. Basically, however, spinal fixation is appropriate to repair mechanical instability due to vertebral collapse; neurological instability where spinal fixation can prevent further neurological injury; and a combination of the two. This is referred to as the 3-column model. Instability has been interpreted as:

50% of the vertebral height lost as the result of inter-disc compression

Furthermore, if a posterior longitudinal ligament injury was identified by MRI in conjunction with a burst fracture, this should be considered for spinal fixation. Another categorization of what is a stable or unstable spine is the AO/Magerl Classification that uses pathomorphological criteria together with three mechanisms of injury, the effect of which needs to be shown up on CT scans and radiographs. The results are categorized as being:

A: compression

B: distraction

C: rotation type fractures

Where the Spinal Canal has been Compromised

When the CT scan reveals a spinal canal has been reduced by 40% - 50% by thorocolumbar burst fractures many surgeons will carry out spinal fixation. Nevertheless, there is no guarantee that, by the time spinal fixation has been carried out, paralysis wouldn’t have occurred. Imaging appears to indicate that the worst spinal occlusion occurs at the place where the most pressure compresses the spinal cord. Despite the prospect of catastrophic injury occurring from burst fractures in the spinal region evidence shows that the spinal canal has the capability to reabsorb intracanal bony fragments in order to help clear the spinal canal. It would appear that this occurs regardless of whether spinal fixation is attempted or not.

Despite this natural clearance technique the body is equipped with, patients who clearly have neurological complications have been shown to be significantly better off following spinal fixation. This has been shown to assist them with earlier mobilization, improved pulmonary function and much greater relief from pain. The prime reason for spinal fixation is to reduce compression on the nerve roots and spinal canal, as well as realign the spine. Surgery is also effective in reducing the incidence of kyphotic deformity as well as increasing the stability, in the long term, for vertebral segments that has suffered trauma.

Certain surgery will be performed in injuries that reveal progressive neurological deterioration, as well as spinal canal compromise in excess of 50%, anterior vertebral body height loss in excess of 50%; incomplete neurological injury; kyphotic deformity of more than 25o – 35o angle; as well as an assortment of contiguous vertebral injury and trauma.

Proposed Treatment Algorithm

A new classification has been proposed by the Spine Trauma Study Group as a treatment algorithm for patients who have experienced thorocolumbar fractures. This algorithm is known as the Thoracolumbar Injury Classification and Severity Score, or TLICSS. It refers to the importance of three types of criteria that need to be considered to establish stability and decide on whether to resort to surgery or rely on conservative treatment. The TLICSS criteria are:

Morphology of the fracture:

1 point – compression

3 points – translational/rotational

4 points – distraction

Neurological Injury:

0 points – intact

2 points – nerve root injury

2 points – cord or conus medularis incomplete injury

3 points – cord or conus medularis complete injury

3 points – cauda equina syndrome

Integrity Status of Posterior Ligamentous Complex:

0 points – intact

2 points – injury suspected/indeterminate

3 points – injured

Total Score: this score measures from 1 – 10 points

For surgery to be considered necessary the criteria needs to exhibit 5 points or less

Non-surgical treatment will be provided when the criteria measures at 3 points or more.

Who is Unsuitable for Spinal Fixation?

Clinicians are far more selective about who undergoes spinal fixation nowadays. Too often in the past spinal fixation was carried out as a remedy for generic lower back pain. Without suitably advanced imaging techniques to prove otherwise, patients were operated on in an attempt to eradicate severe back pain for which no cure could be established. Nowadays, full imaging results are acquired to establish the need for spinal fixation, without which spinal fixation is not carried out. Patients with degenerative disc disease are not considered suitable candidates for spinal fixation and only very rarely is lower back pain treated with spinal fixation.

Devices Used for Spinal Fixation

So many unwarranted misconceptions abound when it comes to spinal fixation that people are understandably concerned about the prospect of having to face such surgery. Obviously, the best way to dispel such concerns is to discuss the various procedures in detail and to investigate who would best benefit from such procedures as well as what patients, having had spinal fixation carried out, can expect from it, as well as how this surgery is likely to affect their lives. Devices to enhance spinal stabilization are used in all areas of the spine, including the cervical, thoracic and lumbar regions.

Basically, a device used for spinal fixation needs to stabilize the posterior spine while limiting compression and enabling the maximum amount of movement. Generically, a spinal fixation device offers a permanent support that is either rigid or semi-rigid. The prosthesis itself is usually made from titanium. They include plates, rods, and screws, any of which could be incorporated into a device to fix an unstable spine. Another fixation device that is used in some instances is the resorbable fixation device made from a bio-resorbable substance such as one of the polymer products. If this is used there needs to be a device to prevent any acid damage occurring that might damage bone near the fixation device.There are various stabilizing techniques that are currently used, all of which are intended to provide additional stability for the posterior aspect of the spine. Most often, nowadays, spinal fixation is the preferred route although in a worst case scenario, spinal fusion is still an option. Spinal fixation is preferred as it tends not to limit range of movement.

The Generic Surgical Procedure for Spinal Fixation

There are all sorts of techniques that are used to undertake surgery for the fixation of the spine. Nowadays, any good surgeon will operate using the least invasive route possible. However, the ultimate outcome has to be the welfare of the patient and the success of the operation. The surgeon is trained to make these decisions on your behalf. First and foremost, minimally invasive surgery really relates to the amount of retraction needed by the surgeon to access the site of the operation to be able to carry out the repair that needs doing. If, during this time, he is able to use some of the newest tools available such as laser techniques then that is what the surgeon will do. However, the surgeon will advise you beforehand what he intends to do. What the surgeon actually does is totally dependent upon what he sees once you are under anesthetic and the surgeon can see the damaged area. The surgeon will then make a decision based on his knowledge, skills and experience, on the best way to complete the surgery successfully.

Expectations from Spinal Fixation

Invariably, patients will be able to resume their normal daily activities within a couple of months following spinal fixation surgery. Patients will notice that, following this surgery, they are largely free of pain, encouraging them to resume their lives where they left off prior to spinal problems preventing them living their lives to the fullest.

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